Obstetric emergencies can occur with and without warning. Some high-risk pregnancies, such as twin gestation or breech presentation, allow the nurse and health-care providers time to prepare for labor and possible emergencies. Other obstetric emergencies, such as a prolapsed cord, occur without warning. The nurse is aware of risk factors that increase the chance of emergencies and is also prepared for a routine labor to become an emergency. Most labor and delivery units practice emergency drills to ensure that everyone is prepared for common emergencies such as postpartum hemorrhage and shoulder dystocia.

Lack of progress during labor, which could make it prolonged or difficult is called dystocia is defined as difficult labor. The types of dystocia are uterine, pelvic, and fetal. Table 19.1 lists the most common risk factors for labor dystocia . Uterine dystocia is caused by lack of power, meaning that uterine contractions or the maternal pushing effort is inadequate to progress to birth. Pelvic dystocia is a problem of the passage, meaning that the pelvic outlet does not allow the passage of the fetus for birth. Fetal dystocia is a problem of the passenger, meaning that the fetus is unable to maneuver through the pelvis to descend and birth. These three types of dystocia create long, difficult labors. The common factors associated with labor dystocia are the following:

• power: uterine contractions and laboring person’s pushing effort
• passenger: fetal malposition or malpresentation
• passage: inadequate pelvis inlet, midpelvis, or outlet
• psyche: laboring person’s preparedness and anxiety regarding the labor and birth process
• position of the laboring person

Life-Stage Context

Labor Dystocia Increases with Age

Advanced maternal age (AMA) is a risk factor for uterine dystocia. The finding that uterine dystocia occurs more often in AMA persons is true; however, studies have shown that the risk of labor dystocia increases with maternal age (Waldenstrom & Ekeus, 2017). After age 25, the risk of labor dystocia increases continuously regardless of parity. Therefore, labor dystocia risk can occur prior to age 35. Labor dystocia increasing with age is related to a continuous decline in uterine performance after age 25.

The labor complication in which lack of cervical dilation occurs due to insufficient contraction strength, frequency, or duration is uterine dystocia (Wu et al., 2017).

Figure 19.2 shows monitor tracings associated with uterine dystocia. In a normal contraction pattern, the upper uterine muscles shorten during the contraction to elongate the lower uterine segment, which causes dilation, effacement, and descent of the fetal head. (Figure 19.3) shows how the muscle fibers of the uterus work together.

Multiple factors cause inadequate uterine contraction activity. Causes related to the pregnant person are chorioamnionitis , dehydration and malnutrition , exhaustion, and emotional stress. Chorioamnionitis can cause the uterine muscle to inadequately contract due to the inflammatory process of infection. Pregnant persons with long labors who are allowed little to eat or drink can become exhausted, hypoglycemic, and dehydrated, preventing the uterine muscles from contracting properly. Emotional stress occurs when fear, pain, or inability to relax releases stress hormones, such as cortisol, that inhibit proper oxytocin production (Aristizabal, 2019). A fetal cause of inadequate contraction patterns can be malposition. The fetus presenting in the occiput-posterior or occiput transverse position creates a larger diameter to pass through the pelvic inlet, making labor progression difficult. The role of the nurse is to encourage hydration, assist with frequent movement and position changes, and provide emotional support to alleviate fear and stress in the laboring person.

Multiple gestation, large for gestational age, and polyhydramnios (an excessive amount of amniotic fluid) distend the uterus and decrease the strength of the contractions, causing uterine dystocia . Grand multiparity and prolonged labor are associated with a uterus too tired or overstretched to contract efficiently. Uterine anomalies, such as bicornuate and unicornuate uteri, are associated with uterine muscle dysfunction. Epidural anesthesia may decrease uterine contraction strength and frequency and has been linked to a nonengaged fetal head (Penuela et al., 2019).

Uterine dystocia can also occur in second stage labor. When the cervix is fully dilated and the fetal head has descended, most laboring persons feel an overwhelming urge to push. The fetus is born by the expulsive strength of the uterine contractions and the maternal pushing effort. Dystocia may occur because epidural anesthesia reduces the urge to push. Second stage dystocia can also result from the same risk factors that cause first stage uterine dystocia. New guidelines for second stage labor recommend that a nulliparous person push at least 3 hours and a multiparous person push at least 2 hours prior to diagnosing dystocia (American College of Obstetricians and Gynecologists [ACOG], 2024). The guidelines do not specify any difference in length with or without an epidural. The role of the nurse during the second stage, especially during dystocia, is to provide support and assist in the pushing process.

A labor complication that occurs when the size of the fetal head is larger than the size of the maternal pelvis due to a small capacity of the pelvic inlet, midpelvis, or pelvic outlet is called pelvic dystocia . In a normal labor, the fetal head descends and engages in the pelvic inlet. As the fetus passes through the pelvis, the head flexes and rotates to the occiput-anterior (OA) position in the midpelvis. The fetal head enters the pelvic outlet in a flexed OA position and is born by the extension of the fetal head. If any part of the pelvis is too small for the fetal head, these cardinal movements cannot occur. At times, the power of the contractions can be adequate, but because of the inability of the fetal head to descend, cervical dilation and effacement stall (Cohen & Friedman, 2023).

Life-Stage Context

Pelvic Dystocia in Teens

Prior to the current study, adolescents were thought to have increased risk of pelvic dystocia because of the immaturity of their pelvis and thus were at higher risk for cesarean birth. Recent studies, however, have not confirmed this assumption.

A study was conducted of 43,537 nulliparous persons less than 25 years of age. The study examining adverse maternal and neonatal outcomes included 1,189 adolescents less than 16 years of age; 14,703 older adolescents ages 16 to 19; and 27,645 young adults ages 20 to 24. Study results found that younger adolescents had increased anemia, preterm delivery, postpartum hemorrhage, and preeclampsia. Older adolescents had increased anemia, preterm delivery, and blood transfusions.

Study results found that younger and older adolescents had decreased risk of cesarean birth. Older adolescents were less likely to have a cesarean birth due to failure to progress or cephalopelvic disproportion. For adolescents who spontaneously went into labor, the study showed their second stage of labor was shorter.

This study challenged the assumption of increased incidence of pelvic dystocia in younger adolescents. However, research on this population is limited, and the topic requires further study.

(Kawakita et al., 2016)

The normal pelvic inlet should allow the passage of a fetal head diameter of approximately 9.5 centimeters (cm) (Figure 19.4). Therefore, if the pelvic inlet is less than 10 cm, it could cause inability of the fetal head to engage and pass through the inlet.

Figure 19.4 Pelvic Inlet The pelvic inlet must be adequate for the fetal head to enter and pass through to avoid pelvic dystocia. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Midpelvis dystocia is more common than pelvic inlet dystocia. The midpelvis is measured by the distance between the ischial spines and should average more than 9 cm (Figure 19.5). When the nurse is performing a cervical exam during labor, the ischial spines are the landmark for determining station. If the ischial spines are encroaching and prominent, the nurse is aware that a midpelvis dystocia could occur. With a smaller midpelvis, the fetal head engages but is unable to flex or rotate anteriorly. Molding and caput succedaneum are seen with this dystocia.

Figure 19.5 Midpelvis A midpelvis dystocia occurs when the ischial spines are prominent and encroaching. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Pelvic outlet dystocia is seen when the ischial tuberosity distance is less than 8 cm (Figure 19.6). When the pelvic outlet is contracted or too small, the fetal head can become malpositioned as the fetus attempts to turn the head to find the path of least resistance to progress through the pelvis. Extreme caput succedaneum can occur. Pelvic outlet dystocia can lead to prolonged pushing, forceps birth, or cesarean birth.

Figure 19.6 Pelvic Outlet A pelvic-outlet dystocia occurs when the ischial tuberosities are encroaching and not allowing descent of the fetal head. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The labor complication in which the fetal head is unable to navigate through the pelvis is fetal dystocia . Reasons for fetal dystocia can be a persistent occiput posterior or transverse, face, or brow presentation . Occiput posterior or transverse position s can stall cervical dilation due to lack of even pressure exerted on the cervix. These positions can also lead to failure of the presenting part to descend. A face presentation occurs when the neck is hyperextended and the chin, also called the mentum, is presenting. This presentation, occurring in only 0.1 percent of births, is caused by prematurity, pendulous maternal abdomen, fetal malformations (anencephaly), and polyhydramnios (Mohammed & El-Chaar, 2022). Some face and brow presentations are seen with large fetuses and contracted pelvis inlets. A vaginal delivery is possible if the chin is directed at the maternal symphysis pubis (mentum anterior) (see Figure 15.8). It is impossible for a fetus to navigate the pelvis if the chin remains posterior and pointing toward the maternal back (mentum posterior); a cesarean birth is necessary (Mohammed & El-Chaar, 2022). The role of the nurse is to support and educate the laboring person and family regarding the possible changes in birth plan to a forceps or cesarean birth.

When labor dystocia has been diagnosed and uterine dystocia is the cause, the nurse understands that interventions must be done to increase the strength, frequency, and duration of uterine contractions. At other times, fetal or maternal complications require the nurse to induce contractions for labor induction when the pregnant person has a medical reason that necessitates delivery of the fetus. Oxytocin ( Pitocin ) is the medication primarily used to augment and induce labor. The nurse administers the oxytocin and monitors the uterine contractions, fetal heart rate, and labor progress.

Factors that improve success of labor induction and augmentation include younger age, body mass index 30, favorable cervix, and estimated fetal weight less than 3,500 grams. Failure of induction is higher in cases of an unfavorable cervix. In some cases, preinduction cervical ripening can be initiated.

The physiologic influences on uterine contractions are multifactorial. Research has yet to determine the exact biochemical substances that initiate labor; however, once labor is initiated, maternal oxytocin is released in pulses, causing the involuntary activation of uterine smooth muscle fibers. While most patients have adequate contractions that allow for the progression of labor, some may have contractions that are inadequate. In these cases, labor augmentation with intravenous oxytocin is used. The nurse titrates the oxytocin to induce adequate contractions for progression of labor while allowing for uterine relaxation between contractions and fetal oxygenation.

Oxytocin binds to receptors in the uterine muscle to stimulate contractions. The response to oxytocin depends on many factors (Uvnäs-Moberg, 2023). If a pregnancy is not yet considered term, the uterus has fewer oxytocin receptors and does not respond to intravenous oxytocin in the same way as a term uterus. Other factors affecting oxytocin response are individual biological differences, length of labor, cervical status, and preexisting uterine activity.

Insufficient Contraction Frequency and Strength

Adequate contraction patterns are defined as uterine contractions with enough duration, strength, and frequency to cause progressive cervical dilation and fetal descent (Rosen & Yogev, 2023). Insufficient contraction patterns lead to insufficient cervical dilation, fetal descent, and labor dystocia . The frequency of uterine contractions is determined by measuring the minutes from the beginning of one contraction to the beginning of the next contraction. Coupling or tripling of contractions can occur and is most often associated with dysfunctional labor, cephalopelvic disproportion , or the occiput posterior position. Figure 19.7 shows a monitor tracing that indicates uterine contraction coupling. The nurse can estimate uterine contraction strength using palpation or can calculate exact uterine contraction strength in Montevideo units using an intrauterine pressure catheter . The nurse uses these techniques to help determine adequacy of the contractions.

Uterine Tachysystole

More than five contractions occurring in 10 minutes averaged over 30 minutes is called uterine tachysystole . Uterine tachysystole does not allow enough time between contractions for placental perfusion and fetal reoxygenation. If allowed to continue, this can lead to fetal hypoxia or uterine rupture . Figure 19.8 illustrates uterine tachysystole on a fetal monitor tracing . The typical uterine contraction pattern is three to five contractions in 10 minutes. Common causes of tachysystole are administration of cervical ripening and inductive medications. Other causes can be maternal dehydration, preeclampsia , placental abruption, and chorioamnionitis (Leathersich et al., 2018). Additionally, partial placental abruption allows blood to seep into the uterine muscle, causing uterine irritability and eventual tachysystole (Sukumaran et al., 2021). Uterine tachysystole can lead to fetal hypoxia because of the diminished blood flow while the uterus is contracting.

Clinical Safety and Procedures (QSEN)

Management of Uterine Tachysystole

Uterine tachysystole is defined as more than five contractions in 10 minutes averaged over 30 minutes. When administering oxytocin for induction or augmentation of labor, uterine tachysystole is a risk factor. The following interventions should be used when uterine tachysystole is diagnosed.

For uterine tachysystole with nonreassuring fetal heart rate pattern:

1. Discontinue oxytocin.
2. Turn laboring patient to lateral position.
3. Administer 500 mL intravenous (IV) bolus (unless contraindicated).
4. Administer 0.25 mg terbutaline subcutaneously (SQ) (when ordered).

For uterine tachysystole with reassuring fetal heart rate pattern:

1. Reposition laboring patient (left or right lateral position).
2. Administer 500 mL IV bolus (unless fluid restricted).
3. If uterine activity does not return to the expected normal pattern within 10 minutes, follow institution protocol for decreasing or discontinuing intravenous oxytocin.
4. Have terbutaline 0.25 mg SQ readily available.

(Lyndon & Wisner, 2022)

The enhancement of uterine contractions that have failed to cause cervical dilation, effacement, or fetal descent is called labor augmentation . Amniotomy is often used to augment labor. The fetal head must be engaged in the pelvis prior to an amniotomy to reduce the risk of a prolapsed cord . ACOG (2019c) found that amniotomy alone during normal, spontaneous labor did not decrease the time to delivery or affect the incidence of cesarean birth. When amniotomy was performed for labor augmentation in combination with oxytocin administration, labor was shown to be expedited by 1 to 1.5 hours. Oxytocin alone is another method of labor augmentation. The nurse starts oxytocin and increases or decreases the rate according to the uterine contraction pattern, fetal tolerability to the contractions, and health-care provider orders. Table 19.2 lists the indications and contraindications for augmentation of labor.

The goal of augmentation with intravenous oxytocin is to produce uterine contractions that are strong and frequent enough to cause cervical change while also allowing for sufficient fetal oxygenation. Oxytocin is administered using an infusion pump and infused in milliunits per minute. Typically, oxytocin infusion begins at 1 to 2 milliunits per minute and increases 1 to 2 milliunits per minute every 15 to 30 minutes until an adequate contraction pattern is obtained. The typical time for the uterus to respond to the initiation of the infusion is 3 to 5 minutes. When an oxytocin infusion is stopped, the amount of oxytocin in the plasma rapidly declines due to the drug’s 3- to 5-minute half-life (U.S. Food and Drug Administration (USFDA), n.d.). The maximum dose of oxytocin is usually determined by hospital protocols or individual health-care providers. The nurse discontinues the oxytocin infusion in the presence of tachysystole, nonreassuring fetal heart rate pattern, and suspected uterine abruption or rupture, and notifies the health-care provider immediately.

Adverse effects of oxytocin use include fetal distress, water intoxication, and, in rare situations, uterine rupture and urinary retention. Fetal distress occurs when contraction frequency does not allow for adequate fetal recovery and oxygenation. Water intoxication can occur because oxytocin has an antidiuretic action. Uterine rupture is rare in an unscarred uterus. The uterus that has been scarred from a cesarean birth or myomectomy is at higher risk of rupture with oxytocin use.

Pharmacology Connections

Oxytocin (Pitocin)

The labor and delivery nurse administers oxytocin for induction or augmentation of labor, as well as during the third stage of labor to control postpartum bleeding. Oxytocin can also be used as one of several medications for the treatment of postpartum hemorrhage.

• Generic Name: oxytocin
• Trade Name: Pitocin
• Class: uterotonic
• Mechanism of Action: binds to oxytocin receptors in the myometrium, increasing intracellular calcium and stimulating uterine contractions
• Indications: labor induction or augmentation, postpartum hemorrhage, abortion adjunct
• Contraindications: fetal distress, uterine hyperactivity/hypertonicity, cord prolapse, placenta previa, unfavorable fetal position
• Route: intravenous, intramuscular
• Dose: 0.5 to 2 milliunits/minute, increasing 1 to 2 milliunits/minute for induction or augmentation of labor; 10 to 20 units intramuscularly (IM) after delivery of the anterior fetal shoulder or after delivery of the placenta until the uterus is firmly contracted
• Black Box Warning: Pitocin is listed as a high-risk medication by the FDA.

(Davis’s Drug Guide for Nurses, 2021)

The stimulation of uterine contractions prior to the spontaneous onset of labor is induction of labor . When determining the appropriateness of labor induction, the benefits to the pregnant person or fetus must outweigh the risk of continuing the pregnancy. Table 19.3 reviews the criteria, indications, and contraindications of labor induction.

Prior to labor induction, the cervix is evaluated to determine if it is ready for labor. This is called a “ripe” or “favorable” cervix. The Bishop score is a tool used to determine if the cervix is favorable. Table 19.4 presents the components of the Bishop score. The higher the Bishop score, the more favorable the cervix. A labor induction is more successful with a higher Bishop score. If the score is low, the nurse anticipates using a cervical ripening agent to prepare the cervix for labor (Kuba et al., 2023).

Cervical ripening agents can be prostaglandins inserted near the cervix, oral prostaglandins, or mechanical devices such as a Foley or double balloon catheter that manually softens and dilates the cervix. These ripening agents are used prior to induction medications. Misoprostol ( Cytotec ) and dinoprostone ( Cervidil ) absorb systemically. If tachysystole occurs, dinoprostone can be removed from the vagina. Misoprostol cannot be removed from the patient’s system; therefore, a tocolytic can be administered if tachysystole occurs.

Pharmacology Connections

Cervical Ripening Medications: Misoprostol and Dinoprostone

Cervical ripening medications come in tablets, gel, suppositories, and tampon-like inserts. Misoprostol and dinoprostone are both prostaglandins used for cervical ripening. They are very similar in their mechanisms of action but differ in administration routes.

Misoprostol (Cytotec)

• Class/Action: prostaglandin
• Route/Dosage: oral: 50 mcg every 4 to 6 hours; vaginal: 25 to 50 mcg every 4 to 6 hours
• High Alert/Black Box Warning: Use in pregnant women can cause birth defects, abortion, premature birth, or uterine rupture.
• Indications: cervical ripening, labor induction/augmentation
• Mechanism of Action: prostaglandin E1; relaxes cervical smooth muscle; stimulates uterine contractions
• Contraindications: history of uterine surgery, cephalopelvic disproportion suspected, fetal distress, unexplained vaginal bleeding, fetal malpresentation
• Adverse Reactions/Side Effects: uterine tachysystole, abdominal or stomach cramps, fever, chills, vomiting, diarrhea
• Storage: stable at room temperature
• Cost: inexpensive
• Nursing Implications: The nurse will ensure fetal well-being prior to administration of medication.
• Parent/Family Education: The nurse will educate the person on the administration of the medication and expected results of cervical ripening or active contractions.

Dinoprostone (Cervidil, Prepidil)

• Class/Action: prostaglandin
• Route/Dosage: vaginal: suppository/tampon-like insert: 10 mg for up to 12 hours; gel: 0.5 mg per applicator every 6 hours for 2 doses
• High Alert/Black Box Warning: none
• Indications: cervical ripening
• Mechanism of Action: prostaglandin E2; relaxes cervical smooth muscle; stimulates uterine contractions
• Contraindications: history of uterine surgery, cephalopelvic disproportion suspected, fetal distress, unexplained vaginal bleeding, fetal malpresentation
• Adverse Reactions/Side Effects: Uterine tachysystole, abdominal or stomach cramps, fever, chills, vomiting, diarrhea
• Storage: must be refrigerated
• Cost: expensive
• Nursing Implications: The nurse will ensure fetal well-being prior to administration of medication.
• Parent/Family Education: The nurse will educate the person on the administration of the medication and expected results of cervical ripening or active contractions.

(Nadar & Sirisha, 2018)

When the health-care provider inserts a Foley catheter for mechanical cervical ripening, a catheter with a 25- to 50-milliliter balloon is inserted through the cervical canal. The balloon is inflated with sterile saline or water. The balloon puts pressure on the internal cervical os. The balloon is usually in place for 8 to 12 hours. When using a double balloon catheter with two balloons, the catheter is inserted through the cervical canal. The balloon at the internal cervical os is inflated with 30 to 60 milliliters of sterile saline or water. The balloon at the outer cervical os is then inflated. The catheter remains in place between 12 and 24 hours. The role of the nurse is to educate the laboring person and assist the health-care provider during insertion. Figure 19.9 shows these two mechanical cervical ripening agents.

Oxytocin is the most commonly used medication for labor induction. When oxytocin is administered for the induction of labor, the nurse prepares the pregnant person by explaining the purpose of oxytocin use.

• Oxytocin is mixed in different combinations. The nurse must be aware of the amount of oxytocin per milliliter of fluid.
• Oxytocin is infused via a pump.
• Starting dose is usually 0.5 to 2 milliunits/minute.
• The dose is increased according to institution protocol, most frequently by 1 to 2 milliunits/minute every 30 minutes until an adequate contraction pattern is obtained.
• The maximum oxytocin dose is usually determined by the health-care provider or hospital protocol.

Pharmacology Connections

Terbutaline

The nurse caring for laboring persons will at times administer terbutaline to relax the uterus, as in cases of fetal bradycardia, tachysystole, Category III tracings, and preterm labor. Terbutaline can be used in antepartum and intrapartum situations.

• Generic Name: terbutaline
• Trade Name: none
• Class: tocolytic
• Mechanism of Action: selectively stimulates beta-2 adrenergic receptors, relaxing smooth muscle
• Indications: bronchospasm, tocolysis (preterm labor, tachysystole, prolonged deceleration)
• Contraindications: hypersensitivity to drug, ischemic heart disease, hypertension, arrhythmia, diabetes mellitus, seizure disorder, hyperthyroidism, tachycardia (>120)
• Route: subcutaneous injection
• Dose: 0.25 mg every 20 to 30 minutes, maximum of 1 mg per 4 hours
• Black Box Warning: Injectable terbutaline not approved for prolonged tocolysis greater than 48 to 72 hours. Serious adverse effects include increased heart rate, transient hyperglycemia, hypokalemia, cardiac arrhythmias, pulmonary edema, myocardial infarction, and death reported after use in pregnant persons; increased fetal heart rate and neonatal hypoglycemia may also occur.

(Davis’s Drug Guide for Nurses, 2021)

The process of replacing amniotic fluid by adding fluid back to the uterus is amnioinfusion . The technique is done through the port on the intrauterine pressure catheter . A bag of normal saline or lactated Ringer solution is connected to the catheter port and infused as a bolus or at a continuous rate. Indications for amnioinfusion are umbilical cord compression. The extra fluid allows more space for the umbilical cord and can relieve cord compression. Prelabor rupture of membranes can cause umbilical cord compression or malposition of the fetal head.

Amnioinfusion can help lower the risk for cesarean birth or vacuum or forceps use; can dilute meconium; and can improve Apgar scores (Narbhavi et al., 2020). Amnioinfusion is contraindicated during fetal distress , active genital herpes infection, placenta previa , placental abruption , or fetal malpresentation . Complications can occur during amnioinfusion. The most common complications are chorioamnionitis , umbilical cord prolapse, prolonged labor, and perforated uterus. The nurse will monitor the pressure of the uterus during the amnioinfusion to avoid overdistention.

During labor, complications can occur that involve the amniotic fluid, such as oligohydramnios or polyhydramnios, meconium passage, precipitous labor, and infection. Complications can occur because of fetal issues such as multiple gestation, intrauterine fetal demise, malpresentation, and fetal anomalies. The pregnant person can also develop complications during pregnancy that affect labor, such as preterm or postterm pregnancy, preeclampsia, and gestational diabetes. The nurse caring for such persons must understand the nursing interventions associated with these complications.

The amniotic sac, also called the bag of waters, consists of the amnion and chorion. The amnion is the inner layer and the chorion the outer layer. They lie so closely together that sometimes they cannot be separated. The bag is filled with amniotic fluid. The purpose of the amniotic fluid is to provide cushioning to protect the fetus, to maintain an appropriate temperature, and to allow the fetus to move and grow unrestricted.

Complications surrounding the amniotic fluid consist of meconium-stained fluid , oligohydramnios, polyhydramnios, and chorioamnionitis. These complications can affect the quality of labor and pose risks to the fetus and laboring person. Oligohydramnios and polyhydramnios are more likely to be diagnosed prior to labor, while meconium-stained fluid and chorioamnionitis will likely be diagnosed during labor.

Meconium-Stained Amniotic Fluid

The brown or green staining of amniotic fluid due to the fetal passage of meconium is called meconium-stained amniotic fluid (MSF) . Meconium passage can be attributed to normal gastrointestinal function, fetal response to hypoxia, and vagal response to umbilical cord compression. Two risk factors for MSF are postterm pregnancy and fetal distress (Mitchell & Chandraharan, 2018). Meconium aspiration is the most common complication related to MSF and can lead to neonatal pneumonia. The diagnosis of meconium aspiration is by observation of symptoms and chest x-ray.

Treatment of MSF in labor consists of amnioinfusion and preparation for resuscitation. The nurse calls the neonatal intensive care unit (NICU) team to be present at the birth. The neonatal team is prepared for resuscitation if needed. If the newborn is vigorous at delivery, no suctioning is necessary. If the newborn is not vigorous, the neonatal team will initiate the steps of neonatal resuscitation. The newborn would most likely go to the NICU for continued observation.

Oligohydramnios

Oligohydramnios is the lack of sufficient amniotic fluid. This amount is usually measured during ultrasound examination. Causes of oligohydramnios can be fetal or maternal. Identifying the causative agent is important to determine treatment. Indomethacin (Indocin) , a medication used to treat preterm labor, has been associated with oligohydramnios. Fetal kidney and bladder disturbances and anomalies also lead to oligohydramnios. Table 19.5 reviews the diagnosis, causes, and symptoms of oligohydramnios.

Complications of oligohydramnios during pregnancy can be fetal growth restriction and fetal malformations. In cases of severe oligohydramnios, induction of labor is warranted. Complications during labor consist of nonreassuring FHR tracings, such as variable and prolonged decelerations due to cord compression during uterine activity. Amnioinfusion can replace fluid in the uterus to relieve umbilical cord compression during labor (Narbhavi et al., 2020).

Polyhydramnios

An increase in amniotic fluid amount, or polyhydramnios, may be caused by fetal abnormalities or genetic syndromes and conditions of the pregnant person. Two common reasons for polyhydramnios are fetal anomalies and diabetes in the pregnant person. Table 19.6 reviews the diagnosis, causes, complications, and associated discomfort of polyhydramnios.

Complications include premature labor, prelabor rupture of membranes, and postpartum hemorrhage because the uterine muscle is stretched more than with normal amniotic fluid levels; umbilical cord prolapse because the fetus does not descend into the maternal pelvis, allowing the umbilical cord to lie below the fetal presenting part; and stillbirth due to the increased risk of congenital anomalies and antepartum placental abruption . Placental abruption can occur after rupture of membranes due to the decompression of the uterus. Treatment depends on the etiology and gestational age. Labor induction can be initiated because of polyhydramnios. The nurse is aware of the increased risks of prolapsed cord and postpartum hemorrhage and is prepared for these complications. Polyhydramnios has been associated with fetal anomalies. Amniocentesis is sometimes used to remove excess amniotic fluid to relieve discomfort and prevent preterm birth ; additionally, this fluid can also be used to test fetal chromosomes for abnormalities (Content Engine, 2023).

Chorioamnionitis

Chorioamnionitis, also known as intraamniotic infection and inflammation, is the infection and inflammation of the amniotic fluid, placenta, fetus, fetal membranes, or decidua (ACOG, 2017b). Chorioamnionitis is caused by different types of bacteria present in the vagina that ascend into the amniotic area. Risk factors during labor include prolonged labor, multiple vaginal exams , use of internal fetal monitors, meconium-stained fluid, and genital tract bacteria (ACOG, 2017b). Complications associated with chorioamnionitis are neonatal morbidity from pneumonia, meningitis, sepsis, and death. Complications in the laboring person consist of dysfunctional labor, postpartum atony, postpartum hemorrhage, endometritis , sepsis, and, rarely, death (ACOG, 2017b). Table 19.7 lists other characteristics of chorioamnionitis.

Symptoms of chorioamnionitis are tachycardia in the laboring person and/or fetus, uterine tenderness, foul-smelling amniotic fluid, and purulent cervical discharge. Culture of the fluid would be the best diagnostic tool; however, the laboring person does not have the time to wait on culture results. Therefore, diagnosis is determined by clinical presentation. The person is treated with broad-spectrum antibiotics (Conde-Agudelo et al., 2020). The antibiotic regimen is usually continued until after the birth. The role of the nurse is to treat the symptoms according to the health-care provider’s orders, monitor for distress in the laboring person and fetus, and explain the purpose of the medications being administered.

Clinical Judgment Measurement Model

Recognize Cues of Chorioamnionitis

The nurse must be aware that chorioamnionitis can lead to sepsis (Zhao et al., 2020). Therefore, recognizing the early signs of infection will allow the laboring person to be treated prior to sepsis developing. The nurse will observe for these signs of infection:

• tender uterus,
• foul-smelling discharge,
• fetal tachycardia, and
• nonreassuring FHR.

If the chorioamnionitis has progressed, the nurse will recognize these cues of sepsis:

• hypotension,
• confusion,
• diarrhea,
• vomiting, and
• diaphoresis.

The fetuses of a multiple gestation are at higher risk for complications during labor and birth. The complications include cord entrapment and disproportionate distribution of oxygen and nutrients to one fetus. Malpresentation can cause complications such as descent of the fetal head in labor or prolapsed cord. A postterm pregnancy poses a threat for fetal growth restriction due to lack of perfusion of oxygen and nutrients associated with an aging placenta. Because of this lack of oxygenation and nutrition, the fetus moves less to conserve energy, slows or stops growth, and uses fat as energy. Conditions such as fetal anomalies are known prior to labor in the majority of cases. However, some conditions are missed or not evaluated for, and the fetus can be at risk due to lack of preparation for the anomaly. Finally, when the fetus has experienced a traumatic event in utero and cannot compensate, the fetus does not survive. The term for a fetus at greater than 20 weeks’ gestation that is not living but still in the uterus is intrauterine fetal demise (IUFD).

Multiple Gestation

Multiple gestations are prevalent because of the various assisted reproductive techniques available. In 2018, the rate of twin pregnancies was 32.6 twins per 1,000 total births (ACOG, 2021). Multiple gestation pregnancies rarely progress to 40 weeks. Recommendations for delivery in a normal twin pregnancy is delivery within the 38th week (ACOG, 2021). Delivery of a complicated twin pregnancy is determined according to the complication and degree of prematurity.

Complications of multiple gestation during labor and birth include uterine labor dystocia , abnormal fetal presentation, umbilical cord prolapse, placental abruption, emergent operative delivery , and postpartum hemorrhage (ACOG, 2021). Therefore, safety measures are instituted to prepare for complications. The nurse maintains continuous fetal monitoring for both FHR s, ensures blood is readily available, and has a sonography machine in the room to evaluate the presentation of the fetuses during labor. The labor and delivery surgical suite is available for delivery of twins or an emergency cesarean birth. Each newborn will have a separate pediatric team with two of all equipment.

Intrauterine Fetal Demise

Intrauterine fetal demise ( IUFD ) occurs in 1 in 160 births and is normally caused by fetal hypoxia. Sometimes, however, the cause is unknown (Metz et al., 2020). One cause of IUFD can be placental insufficiency due to disease, postterm pregnancy, or placental infarcts (Fadel & Mashally, 2022). Placental abruption is a risk factor for IUFD. Umbilical cord accidents such as knots, loops, or prolapse can cause IUFD. During labor, IUFD can occur due to malpresentation, prolonged labor, cord accidents, and hypoxia. Table 19.8 lists the causes and incidences of IUFD.

Many risk factors for IUFD have been identified, but most of these risk factors cannot be used to predict or prevent stillbirth. However, a history of prior stillbirth greatly increases the risk of repeat stillbirth. Nulliparity, advanced maternal age , obesity, preexisting diabetes, chronic hypertension , multiple gestation, smoking, and use of alcohol during pregnancy have been associated with IUFD (Metz et al., 2020). Autopsy and DNA testing can be performed with parental consent to determine the cause of death in hopes of preventing another demise. The role of the nurse is to discuss options with the laboring person and family regarding holding the baby, taking pictures, and spending time with the baby. The nurse plays a large role in emotionally supporting the person and family. This can be emotionally difficult for the nurse, and many labor and delivery units have access to support groups, social workers, or counselors that help the nurse as well as train nurses in assisting with perinatal bereavement.

Malpresentation of the Fetus

When the fetus is in a malpresentation , labor is more difficult for the fetus and the laboring person. The fetal head presents in the pelvis for 95 percent of labors and is breech in 3 to 4 percent of labors (Mohammed & El-Chaar, 2022). Risk factors for fetal malpresentation are unstable fetal lie, contracted pelvis, pendulous abdomen, uterine anomalies , and abnormal placenta location. The fetal risk factors include large infant, abnormal internal rotation, fetal extension, multiple gestation, and polyhydramnios.

Malpresentation can cause higher rates of operative deliveries. Prolonged labor or labor dystocia is common. Many times, the cervix will dilate or efface slowly because the fetal head is not compressing the cervix. Fetuses in an abnormal lie will have more molding and caput succedaneum, and they might also have lower Apgar scores due to long, difficult labors.

The most common malpresentation is the occiput posterior presentation. This occurs in 15 to 30 percent of cephalic presentations (Mohammed & El-Chaar, 2022). Figure 19.10 illustrates the occiput posterior position. The cause of this and many malpresentations is cephalopelvic disproportion . The nurse can help place the laboring person in hands-and-knees, forward-leaning, or side-lying positions to encourage rotation of the fetal occiput. If this presentation does not resolve, it is called a persistent occiput posterior position. Although vaginal delivery does occur in persistent posterior positions, the incidence of labor dystocia and fetal distress is significantly higher than in fetal occiput anterior positions.

Brow presentation occurs when the forehead of the fetus is presenting and is slightly extended. Because the diameter of the brow presentation is larger than the occiput presentation, this can cause cephalopelvic disproportion. Often the fetus rotates out of this position and either flexes to a vertex presentation or extends to a face presentation. Face presentation increases the risk of cesarean birth. See Figure 15.8 for illustrations of brow and face presentations.

Face presentation is similar to brow; however, in this presentation, the fetal head is totally extended. The presenting part is the face, and the position is determined by the chin, or mentum. The mentum anterior position allows for passage through the pelvic outlet. The mentum posterior position can cause the fetal head to become wedged. If the position is mentum posterior, cesarean birth is recommended. The nurse is aware that the newborn birthed in the face presentation will have edema and bruising of the face and prepares the parents for the newborn’s appearance.

Breech presentation occurs when the fetal sacrum is leading into the pelvis. Three to 4 percent of births are breech at term. The preterm fetus has the highest incidence of breech presentation . Most fetuses will position to cephalic by 34 weeks’ gestation. Maternal factors that increase the incidence of breech presentation include relaxed uterine muscles of a high-parity person, polyhydramnios , uterine anomalies, uterine masses, and contracted pelvis (Elfazari & El-Chaar, 2022). Placental factors include implantation at the fundal region of the uterus and placenta previa . Fetal factors include multiple gestation, hydrocephaly, anencephaly, chromosomal anomalies, and IUFD.

Breech presentation can be classified as frank, incomplete (footling), or complete, as shown in (Figure 19.11). Frank breech is the most common type of breech. Complications of vaginal breech birth are prolapsed cord, fetal asphyxia, and fetal injury. Double footling breech poses the highest risk for prolapsed cord, while frank poses the lowest risk. Footling breech maneuvers easily through the pelvis but allows less dilation for the fetal head to pass. Frank is the largest of the breech presentations, allowing the largest degree of dilation and making more room for the fetal head to birth (Elfazari & El-Chaar, 2022). In a breech position, the fetal head does not mold but remains round. This increases the risk of head entrapment and head trauma. Intracranial hemorrhage is a major concern for breech birth and fetal mortality (Elfazari & El-Chaar, 2022).

Birth of the breech fetus can be either vaginal or cesarean. Research has shown markedly reduced cases of fetal death during delivery with elective cesarean births (Elfazari & El-Chaar, 2022). Providers must be skilled at performing a breech cesarean birth because of the placement of the incision and ability to deliver the fetal head. The pregnant person with a large fetus, oligohydramnios , contracted pelvis, or prior cesarean should consider an elective cesarean birth.

Postterm Pregnancy

A pregnancy extending past 42 weeks and 0 days is considered postterm (ACOG, 2014). Risk factors for postterm birth are unclear; however, nulliparity, prior postterm pregnancy , male fetus, anencephaly, and maternal obesity have been suggested (ACOG, 2014). Some research suggests the placenta has limited capacity and leads to postmaturity syndrome when the pregnancy progresses past term (Patel & Rathod, 2022). Table 19.9 lists the adverse outcomes of postterm birth.

Characteristics of postterm syndrome are a newborn with wrinkled, patchy, peeling skin; a wasted-looking body, and an old appearance. Skin of the hands and feet are wrinkled and peeling due to lack of vernix caseosa. The nails are also long. Postmature newborns can have brown or green-tinged skin from meconium-stained fluid . During labor, the postterm fetus is at risk for uteroplacental insufficiency and oligohydramnios and the risk factors associated with both. The nurse will recognize FHR late decelerations because of uteroplacental insufficiency and variable decelerations because of cord compression. Amnioinfusion can help replace fluid to prevent cord compression. The postterm newborn is at risk for meconium aspiration.

Known and Undetected Fetal Anomalies

Some fetal anomalies are diagnosed during pregnancy, and preparations are made to address the anomaly during labor and birth. Other anomalies can be unexpected and require nursing interventions. One example is gastroschisis, an abdominal wall defect allowing the bowel to herniate into the amniotic sac.

Another condition that needs attention after birth is spina bifida, which can occur anywhere on the spine. Spina bifida is a neural tube defect that can occur in different types:

• spina bifida occulta: the mildest form; defect is a small dimple in the spine without outpouching of a sac
• meningocele: a protrusion of a sac filled with spinal fluid; no spinal cord involvement
• myelomeningocele: the most severe form; a protrusion of a sac containing spinal fluid and part of the spinal cord and nerves (Centers for Disease Control and Prevention [CDC], 2020).

After birth, the infant is placed prone to avoid putting pressure on the herniation. The herniated sac is at risk for infection. The nurse protects the sac by covering it with a moist sterile dressing.

Fetal Distress

Fetal distress occurs when the fetus is not receiving sufficient oxygenation. Uteroplacental insufficiency is the most common reason for fetal distress . Causes of uteroplacental insufficiency can be the use of uterotonics causing tachysystole , maternal hypotension, prolonged umbilical cord compression, and aged placenta.:

• ruptured uterus
• severe placental abruption
• umbilical cord prolapse
• amniotic fluid embolus
• vasa previa causing fetal exsanguination (ACOG, 2014)

Unexpected complications can occur during the process of labor and birth, and the complications can occur rapidly. Preterm labor can occur with preterm rupture of membranes or because of an infection of the uterus. Precipitous labor is very rapidly progressing labor. Preeclampsia can progress through pregnancy and quickly worsen, necessitating labor induction . Diabetes mellitus can age the placenta, causing uteroplacental insufficiency. All of these complications come with risks for the fetus and laboring person. The nurse is aware of assessments and interventions to diagnose and address these problems.

Preterm Labor

Any labor occurring from 20 to 36 6/7 weeks’ gestation is considered preterm labor. Preterm birth can occur spontaneously through preterm labor or preterm prelabor rupture of membranes. Spontaneous preterm labor is caused by many factors, among them, premature cervical dilation or cervical insufficiency, uterine fundal abnormalities, infection, and fetal anomalies (CDC, 2023). Uterine distention, the result of multiple gestation and polyhydramnios, also causes preterm labor.

Preterm prelabor rupture of membranes (PPROM) refers to rupture of membranes prior to the 37th completed week of gestation and before spontaneous labor. The most common causes of PPROM are low socioeconomic status, smoking, multiple gestations, polyhydramnios , gestational hypertension, and diabetes (Danei et al., 2022). Risk factors for preterm labor are prior preterm birth, early pregnancy threatened abortion, birth defects, young and advanced maternal age , and maternal use of cigarettes and illicit drugs. Periodontal disease has also been associated with preterm labor.

Precipitous Labor

Labor and delivery that is extremely rapid, usually less than 3 hours from start of the contractions to birth, is considered precipitous labor . The labor and birth may happen at home, in a birth center, or in the hospital. Pregnant persons may describe their labor as contractions that are very close together without a break between contractions, strong contractions without a slow build, or having a sudden urge to push. The true cause of precipitous labor is unknown; however, several risk factors have been associated with it, such as a small fetus, previous precipitous birth, cocaine use, or high blood pressure. Precipitous birth can lower 1-minute Apgar scores and increase the risk for postpartum hemorrhage, newborn respiratory distress , third- or fourth-degree lacerations , and placental abruption (Aiken et al., 2017; Suzuki, 2015).

Clinical Safety and Procedures (QSEN)

Emergency Vaginal Delivery by the Nurse

1. Call for help.
2. Gather warm blankets.
3. Assist the newborn to birth.
4. Suction mouth and nose if newborn is not crying or if mucus is noted.
5. Place the infant on the birthing person’s chest skin-to-skin.
6. Dry the newborn and keep warm.
7. Clamp and cut the cord.
8. Do not pull on the cord but allow the placenta to deliver spontaneously.

In precipitous labor occurring in the hospital, the nurse focuses on promoting the well-being of the laboring person and the fetus. Patients may have increased anxiety or panic due to the rapid progression. The nurse should speak in a calm manner, explaining what to expect and reassuring the person they are safe. In preparing for the upcoming delivery, the nurse is expected to call the health-care provider and ensure medications to treat postpartum hemorrhage are readily available. If the fetus is born prior to the health-care provider’s arrival, the nurse will gently assist the delivery of the infant, dry the infant, cut the umbilical cord, and place the infant on the birthing person’s chest skin-to-skin. The greatest priority is keeping the infant warm. The pediatric team should be in the room in case the infant does not begin breathing spontaneously after the rapid descent and birth. The nurse should refrain from assisting the delivery of the placenta and allow the placenta to deliver spontaneously. If the placenta delivers spontaneously before the health-care provider is present in the labor and birthing suite, the nurse should be prepared to administer oxytocin per institution protocols to decrease the risk of postpartum hemorrhage.

Preeclampsia

According to ACOG, “Preeclampsia is a disorder of pregnancy associated with new-onset hypertension, which occurs most often after 20 weeks of gestation and frequently near term” (2020b, p. e237). Pregnant patients with a blood pressure (BP) of greater than 140/90 mm Hg are hypertensive. The increased BP requires the nurse to assess the laboring person for other signs of preeclampsia , such as proteinuria, presence of a headache, and visual disturbances. When caring for patients diagnosed with preeclampsia, the nurse monitors the laboring person’s vital signs and symptoms more frequently than those of a low-risk patient.

Complications of preeclampsia can occur during labor and postpartum. It is important for the nurse caring for the laboring person diagnosed with preeclampsia to have a thorough understanding of possible complications and nursing interventions. Complications during labor can be seizure , fetal distress due to uteroplacental insufficiency, and stroke . Headaches, visual disturbances, and hyperreflexia can occur before an eclamptic seizure. Therefore, the nurse explains to the laboring person the importance of reporting headache, epigastric pain, or visual disturbances. The nurse also assesses deep tendon reflexes to determine hyperreflexia. Uteroplacental insufficiency can occur because of the rapid aging of the placenta due to hypertension. Therefore, the nurse monitors for signs of fetal distress during labor. HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome, can cause bleeding issues during labor and postpartum. The nurse reviews the lab work to monitor for signs of HELLP syndrome . Stroke can occur when the blood pressure is critically high (160/110 mm Hg or higher). The nurse explains the importance of monitoring the blood pressure and administering antihypertensive s per protocol to avoid stroke. The nurse also encourages the laboring person to rest and keeps stimulus to a minimum, such as keeping the lights low, limiting visitors, and keeping the room quiet. Severe increases in BP are rechecked and reported to the health-care provider.

Preeclampsia affects the entire body. The kidneys can be affected and cause edema in the extremities and lungs. Strict monitoring of the preeclamptic laboring person’s intake and output (I&O) is essential. The nurse should assess for pedal and facial edema during labor. The nurse also assesses the lungs for signs of pulmonary edema , such as crackles, wheezes, and dyspnea. If the kidneys are affected by preeclampsia, the nurse will limit IV fluids per health-care provider orders. A urine dipstick test for protein might also be ordered. The nurse assesses for epigastric pain, knowing that the laboring person might experience this when the liver is affected.

Medical management of preeclampsia could include antihypertensives and magnesium sulfate. It is important for the nurse to be familiar with the administration, side effects, adverse reactions, and nursing interventions associated with these medications. Nursing assessments for adverse reactions to magnesium sulfate are performed often, and many times the nursing care ratio is one-to-one.

Diabetes Mellitus

Gestational diabetes is a condition causing intolerance to carbohydrates and insulin resistance leading to hyperglycemia in pregnancy. Patients with gestational diabetes are at increased risk for preeclampsia, cesarean birth, and development of diabetes mellitus ( DM ) later in life (ACOG, 2018a).

Persons with type 1 DM must have close monitoring of their blood glucose during labor. The fetus is affected by the laboring person’s glucose level. High maternal blood glucose during labor and birth places the newborn at risk for hypoglycemia. High energy expenditure and limited calorie intake put the laboring person at risk for hypoglycemia as well. The health-care provider will order the frequency of blood glucose checks and insulin infusion. Hourly blood glucose checks are common. Intravenous insulin and glucose must be titrated to keep the person normoglycemic; the goal is to prevent hyperglycemia. Ideal glucose levels in labor are less than 110 mg/dL (ACOG, 2018c).

Gestational diabetes is associated with prelabor rupture of membranes, induction of labor, operative delivery , cesarean birth , and shoulder dystocia . Birth injury to the fetus occurs more often in cases of gestational diabetes, especially with macrosomic infants (over 4,000 g). Newborn injuries include nerve damage, fractures, and cephalohematoma. To reduce risks to the fetus and pregnant person, induction of labor is recommended between 38- and 39-weeks’ gestation (ACOG, 2018a). During labor, the nurse will monitor the laboring person for signs of hypoglycemia. After birth, the newborn will be assessed for hypoglycemia, and glucose will be monitored per facility protocol. The postpartum person is encouraged to breast-feed or bottle-feed often.

Preexisting conditions of the pregnant person can cause increased risk at the time of birth. Some conditions cause birth to be expedited by induction of labor. Other conditions require increased surveillance during pregnancy and birth. Conditions such as heart disease, hypertension, and diabetes mellitus can cause uteroplacental insufficiency and morbidity and mortality of the pregnant person. Musculoskeletal and nutritional complications can cause difficulty during labor for the laboring person or fetus. Knowledge of these preexisting conditions and their effects on the patient and fetus is integral to the nurse monitoring for and managing complications during labor and birth.

Cardiovascular Conditions

Cardiovascular disease in pregnancy accounts for a large percentage of maternal morbidity and mortality in the United States every year (ACOG, 2019c). Cardiovascular disease includes congenital and acquired heart disease , with acquired being on the rise. People with heart disease should labor at an appropriate-level hospital with a care team consisting of an obstetrician, maternal-fetal medicine specialist, cardiologist, and anesthesiologist prepared for any complications.

During labor, preexisting hypertension puts the laboring person at risk for stroke and myocardial infarction; hypertension puts the fetus at risk for uteroplacental insufficiency and fetal distress . Blood pressure must be monitored more closely to determine if antihypertensive medications are necessary during labor. Fetal monitor tracing s must be evaluated often to ensure proper fetal oxygenation.

Heart Disease

Heart disease is also linked to maternal mortality. Some cardiac conditions require alternative plans for labor and birth. Persons with stable heart disease can safely give birth vaginally at 39 weeks’ gestation. Pregnant persons on anticoagulant therapy for cardiac disease will discontinue those medications approximately 12 hours prior to a scheduled induction or cesarean birth (ACOG, 2019c). Pulmonary edema and cardiac arrhythmias require cardiac monitoring during labor. Strict fluid balance is required for prevention of pulmonary edema . Antibiotics could be required during labor to prevent endocarditis. Epidural anesthesia for labor pain can reduce the risk of cardiac arrhythmias (ACOG, 2019c).

The mode of delivery should be discussed with the pregnant person and a multidisciplinary team. People with severe heart failure and acute or chronic aortic dissection should give birth via cesarean birth (Ruys et al., 2013). Marfan syndrome can cause an enlarged aortic root that increases the risk for aortic dissection. If the aortic root is greater than 40 mm, the person should give birth via cesarean birth (Canobbio et al., 2017). People with aortic stenosis and pulmonary hypertension can birth only by passive delivery, meaning avoiding pushing using the Valsalva maneuver (Canobbio et al., 2017). Forceps - or vacuum-assisted delivery is required. Nursing interventions include monitoring vital signs, turning the laboring person to the lateral recumbent position, cardiac monitoring, and closely monitoring fluid input and output (Canobbio et al., 2017).

Hypertension

Preexisting hypertension is the elevation of blood pressure related to peripheral vascular resistance and/or increased cardiac output prior to 20 weeks’ gestation. Preexisting hypertension creates complications during labor by causing uteroplacental insufficiency leading to fetal distress. Severe preexisting hypertension can lead to stroke, cardiovascular disease, and death. Emergency antihypertensive medications should be ordered by the health-care provider when severe hypertension is noted during labor, birth, or the postpartum period.

Diabetes Mellitus

Diabetes mellitus ( DM ) is a metabolic disorder causing elevated blood glucose due to dysfunction in insulin secretion or insulin action (Banday et al., 2020). Diabetes mellitus can be classified as type 1 DM, type 2 DM, or gestational DM. Type 1 DM has been called juvenile-onset diabetes and is caused by an autoimmune disorder that destroys the beta cells of the pancreas and requires insulin. Type 2 DM has also been called non–insulin-dependent diabetes. Type 2 DM is characterized by insulin resistance and beta cell dysfunction (Banday et al., 2020). Preexisting diabetes can cause complications during labor and birth. The most common complication is neonatal hypoglycemia . If the glucose of the laboring person is well controlled, risk for neonatal hypoglycemia is reduced. Other risk factors include cesarean birth, macrosomia , and preterm labor or birth. Shoulder dystocia of the infant is a risk for persons with diabetes. The nurse communicates with the health-care team to be prepared for a possible shoulder dystocia (see 19.7 Obstetrical Emergencies). The nurse will also monitor the laboring person for hyper- and hypoglycemia.

Musculoskeletal Conditions

Several musculoskeletal conditions can affect pregnancy and birth. Muscular dystrophy , a genetic neuromuscular disease that causes weakness and breakdown of skeletal muscles, can lead to preterm birth, intrauterine growth restriction , and congenital malformation (Petrangelo, 2018). Persons with cerebral palsy , a permanent disorder of movement caused by a lesion in the developing brain, are at higher risk for preterm birth , small-for-gestational-age infants, and low 5-minute Apgar scores (Sundelin et al., 2020). Myasthenia gravis is an autoimmune disorder causing muscular weakness that worsens with movement (Roche & Bouhour, 2021). Vaginal operative birth and cesarean birth are more common in those with myasthenia gravis. Epidural anesthesia is appropriate; however, opiates and general anesthetics should be avoided (Roche & Bouhour, 2021). Persons with musculoskeletal issues such as cerebral palsy or an amputation might need special equipment during labor and birth. The role of the nurse is to support the laboring person and assist with ambulation, position changes, and use of special equipment.

Nutritional Status

Nutrition can positively or negatively affect the pregnant person and fetus. Pregnant persons with inflammatory bowel disease , pancreatitis , and intestinal parasites have increased malabsorption (Rahimian, 2019). Malnutrition and malabsorption of nutrients may cause intrauterine growth restriction. The growth-restricted fetus can have increased complications during labor due to uteroplacental insufficiency and lack of fetal reserve. Eating disorders such as anorexia or bulimia can affect absorption of nutrients in the pregnant person and fetus, leading to growth restriction and fetal anomalies (Sebastiani et al., 2020). The most common fetal complications associated with eating disorder s are being small for gestational age, fetal growth restriction, microcephaly, and intraventricular hemorrhage. The role of the nurse is to assess the laboring person’s nutritional status upon admission. If malnutrition or malabsorption is suspected, the nurse will monitor for signs of uteroplacental insufficiency.

Cesarean birth is the birth of the newborn through an incision in the uterus. The incidence of cesarean birth has risen steadily over the past 60 years, with the present rate between 25 and 30 percent (El-Chaar, 2022). The most common indication for cesarean birth is dystocia, fetal or uterine. Fetal conditions, placental issues, and umbilical cord problems are all indications for cesarean birth.

Causes Related to the Person Giving Birth

Cesarean birth can be planned or unplanned. Planned cesarean births can be due to multiple gestation, macrosomia , previous cesarean, active herpes simplex lesions, human immunodeficiency virus (HIV) infection, malpresentation of the fetus, placenta previa, and complications during pregnancy. Unplanned cesarean births can be caused by dystocia , pregnancy complications, and complications during labor. The nurse will educate the family regarding the procedure and what to expect. Pregnant persons can experience increased anxiety and stress because of the unexpected change in their plan for birth. The nurse can help decrease anxiety and stress and, when possible, should allow the significant other to remain with the laboring person.

Dystocia

Labor dystocia can be uterine or fetal. Power, passenger, passage, position, and psyche are the components of dystocia. Therefore, if contractions are not strong enough to cause cervical dilation and fetal descent, a cesarean birth can be performed. When the fetus is unable to pass through the pelvis, fetal malpresentation /malposition or cephalopelvic disproportion can be diagnosed. Other causes of dystocia include uterine masses or neoplasms.

Complications of Pregnancy

Complications of pregnancy such as preeclampsia , gestational DM/DM, and hypertension create increased risk for cesarean birth. Congenital uterine anomaly puts the pregnant person at risk for cesarean birth. Complications of previous pregnancies can also increase a person’s risk. Previous cesarean birth, hysterotomy, myomectomy, and cervical suture can be contraindications for labor, and cesarean birth is required (El-Chaar, 2022).

Preeclampsia

Preeclampsia can cause damage to the placenta. The placenta is affected by hypertension, and perfusion of oxygen and nutrients is decreased to the fetus, which can cause fetal distress prior to or during labor. The pregnant person can become very ill with thrombocytopenia, liver and kidney dysfunction, seizure , or stroke . The cure for preeclampsia is birth and delivery of the placenta. Therefore, pregnant persons who are too ill to labor or continue the pregnancy to term are at higher risk for cesarean delivery.

Gestational Diabetes

Gestational diabetes can cause a large fetus that can be more difficult to birth vaginally. Larger fetuses can cause longer labors and uterine dystocia . Fetal dystocia can be diagnosed due to the larger fetus attempting to maneuver through the pelvis. Gestational diabetes can also affect the functioning of the placenta, causing more fetal distress during labor.

Chronic Medical Conditions

Chronic medical conditions can cause increased risk for cesarean birth. Pregnant persons with HIV are sometimes encouraged to birth via cesarean birth to decrease the vertical transmission rate, especially when the viral load is high (ACOG, 2018e). Persons with heart disease may not tolerate labor and are better suited for cesarean birth.

Hypertension

Pregnant persons with chronic hypertension are at higher risk for preeclampsia, placental abruption , stroke, kidney disease, heart failure, and heart attack. Complications are more common with uncontrolled hypertension, such as pulmonary edema and renal failure. Peripartum cardiomyopathy is another risk factor. Severe hypertension can lead to cerebral hemorrhage and heart failure. Therefore, if these pregnant persons become very ill with these complications, a cesarean birth might be better tolerated than labor.

Diabetes Mellitus

Diabetes mellitus occurring prior to pregnancy can be type 1 or type 2. Both types of diabetes lead to increased levels of circulating glucose. With uncontrolled glucose levels, arteriole damage occurs. This can affect the fetus and placenta. Diabetes is associated with an increased risk of fetal demise. Therefore, pregnant persons with diabetes are monitored more closely as labor nears. If prenatal fetal surveillance shows nonreassuring testing, these persons might undergo labor induction or cesarean birth. This allows the fetus to leave the intrauterine environment that is causing complications.

Fetal causes for cesarean birth include multiple gestation, irregular position, and fetal distress. Twins can be born via vaginal birth if the pregnancy is without complications. However, multiple gestation occurring many times ends in cesarean birth due to cord entanglement and malposition. The fetus in the breech position is most commonly born via cesarean. Fetal distress is a common reason for emergency cesarean birth.

Multiple Gestation

The recommendation for multiple gestation is birth during the 38th week of pregnancy. Labor can be complicated because the overstretched uterus can cause uterine dystocia. Malpresentation and umbilical cord accidents can occur during labor. Postpartum hemorrhage is a risk for multiple gestation pregnancies.

Twins in the vertex-vertex presentation can be delivered vaginally. Vaginal delivery of twins in the vertex-nonvertex presentation is controversial. Twins with the presenting fetus in the breech presentation are recommended to be born via cesarean birth (ACOG, 2021). During the cesarean, the nurse must ensure that the person is not lying completely supine due to the increased weight on the aorta. The nurse must also take steps to maintain family bonding as much as possible.

Breech Delivery

Breech presentation at term can pose a risk to the fetus when born vaginally, including trauma at birth, perinatal asphyxia, lower Apgar scores, and perinatal mortality (Fernández-Carrasco et al., 2022). Research has shown increased perinatal mortality in breech newborns born vaginally (ACOG, 2018b; Bjellmo et al., 2016). Breech presentation causes complications because the presenting part (knees, legs, feet, or buttocks) is smaller than the fetal head or shoulders. Therefore, if the larger head or shoulders cannot fit through the pelvic outlet, the head or shoulders could become lodged under the pubic bone. However, some pregnant persons choose to have a vaginal breech birth over a scheduled cesarean birth. ACOG (2018b) listed the following criteria for a planned vaginal breech birth: gestational age greater than 37 weeks, frank or complete breech presentation , no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2,500 g and 4,000 g. All risks and benefits must be discussed with the pregnant person.

Indications suggesting cesarean birth include patient request, prior neonatal birth trauma, large fetus, oligohydramnios , incomplete breech, pelvic contracture, and prior cesarean delivery. Birth by cesarean must be done carefully to avoid fetal head entrapment or damage to the fetus during incision. Prolapsed cord can be avoided when cesarean birth is scheduled and labor has not started.

Fetal Stress/Distress

Abnormal fetal heart rate suggesting fetal distress can be a cause for cesarean birth. Severe bradycardia, absent variability, and late decelerations are signs of fetal distress. Some fetal distress is caused by the use of oxytocin for induction or augmentation of labor , leading to tachysystole . Umbilical cord prolapse and uteroplacental insufficiency are also causes of fetal distress that can lead to emergency cesarean births. Meconium-stained fluid can be suggestive of fetal distress, but MSF alone is not an indication for cesarean birth.

The umbilical cord can exhibit many different abnormalities, such as loops, knots, vascular malformations, aneurysm, hematoma, abnormal lengths, cysts, and an abnormal amount of Wharton’s jelly (Krzyżanowski et al., 2019). The umbilical cord normally contains two arteries and one vein surrounded by Wharton’s jelly. Abnormal umbilical cords can contain only one artery and one vein. This complication can lead to fetal growth restriction and can also be associated with cardiac and renal abnormalities (Krzyżanowski et al., 2019). Extremely long umbilical cords can cause complications such as true knots, entanglement, and cord prolapse upon rupturing of the membranes. Other umbilical cord abnormalities include those where the umbilical cord is inserted abnormally into the placenta.

Marginal Insertion of the Umbilical Cord

Cord abnormalities involve cord insertions into the placenta. Marginal insertion of the cord into the placenta is any placenta in which the cord inserts along the placental margin and occurs in 6 to 7 percent of pregnancies (Aragie & Oumer, 2021). This variant has also been called battledore placenta. This marginal insertion is not a common reason for cesarean birth; however, this complication could cause fetal distress during labor, necessitating a cesarean delivery.

Velamentous Insertion of the Cord

The labor complication in which the vessels of the umbilical cord branch before reaching the placenta is called velamentous insertion of the cord . The cord is actually inserted into the membranes instead of the placenta (Krzyżanowski et al., 2019). Figure 19.14 demonstrates a velamentous insertion. Complications are fetal growth restriction, cord separation, fetal bleeding, and fetal death. A cesarean birth can prevent fetal exsanguination.

Vasa Previa

The condition in which fetal vessels implant into the membranes and cross over the cervix in front of the fetal presenting part is called vasa previa (Wagner, 2019). Figure 19.15 illustrates a vasa previa. When the membranes rupture or the cervix dilates, the vessels can rupture, causing the pregnant person to bleed excessively and the fetus to exsanguinate. Vasa previa is usually asymptomatic and diagnosed via ultrasound. Because of the very high risk of morbidity and mortality, cesarean birth is preferred, especially prior to rupture of membranes and start of labor.

Obstetric emergencies can occur with and without warning. Some high-risk pregnancies, such as twin gestation or breech presentation, allow the nurse and health-care providers time to prepare for labor and possible emergencies. Other obstetric emergencies, such as a prolapsed cord, occur without warning. The nurse is aware of risk factors that increase the chance of emergencies and is also prepared for a routine labor to become an emergency. Most labor and delivery units practice emergency drills to ensure that everyone is prepared for common emergencies such as postpartum hemorrhage and shoulder dystocia.

Fetal distress is most commonly diagnosed using fetal monitor tracing . The three-tiered categories of FHR tracings guide the nurse and health-care provider to determine the status of the fetus (ACOG, 2009a; Hernandez Engelhart et al., 2023). Category II tracings suggesting difficulty in determining fetal well-being should be monitored to determine if interventions, such as giving an intravenous fluid bolus or repositioning the laboring person, will resolve the issue. After multiple interventions, if the FHR remains Category II, the nurse will continue to monitor the labor progress and the FHR pattern and communicate with the health-care provider. When the nurse interprets the FHR pattern as Category III, the health-care provider is notified. Once the health-care provider confirms the Category III tracing, delivery is expected within 30 minutes (Lyndon & Wisner, 2021). The nurse also contacts the neonatal team to be present at the birth due to the potential complications for the fetus. The nurse keeps the laboring person and family up to date on what interventions are being done and acts as support during this stressful period.

The impaction of the fetal shoulder into the symphysis pubis or sacral promontory, preventing the delivery of the fetus is called shoulder dystocia . It occurs in less than 3 percent of births (ACOG, 2017a). The health-care provider attempts to deliver the anterior shoulder, but the shoulder lodges under the pubic bone and is not delivered. Figure 19.16 illustrates shoulder dystocia. Predicting shoulder dystocia is not always successful. Risk factors for shoulder dystocia are obesity, excessive weight gain, multiparity, increased birth weight, and diabetes (Hill & Cohen, 2016). However, 50 percent of shoulder dystocia occurs in normal-weight fetuses and persons who do not have diabetes; therefore, the nurse should always be prepared for shoulder dystocia. A good predictor of shoulder dystocia is a past shoulder dystocia.

Figure 19.16 Shoulder Dystocia Shoulder dystocia occurs when the anterior shoulder is stuck behind the pubic bone. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Complications of shoulder dystocia include increased risk of postpartum hemorrhage and perineal lacerations . Fetal complications include brachial plexus injuries and fractures of the clavicle and humerus (ACOG, 2017a). These injuries usually resolve; however, shoulder dystocia can cause fetal hypoxia and death.

Management of shoulder dystocia should be systematic and rapid. The nurse and health-care providers must act quickly to resolve the dystocia . The nurse positions the person to help the provider perform maneuvers. The first maneuver is McRoberts maneuver , which is the process of flexing the laboring person’s legs until the thighs touch the abdomen. Posterolateral suprapubic pressure is then provided in hopes of dislodging the shoulder from underneath the pubic bone. The nurse will need a stool to get above the person and give downward, lateral pressure with one or both hands toward the fetal-facing side. See Figure 19.17 for a demonstration of posterolateral suprapubic pressure. The nurse does not give fundal pressure because that impacts the shoulder further. If this maneuver is not successful, the health-care provider will attempt to deliver the posterior arm or attempt to turn the shoulders. The nurse is also prepared to turn the person to hands-and-knees position ( Gaskin maneuver ) if previous maneuvers are not successful. See Table 19.12 for a mnemonic, HELPERR, to remember the maneuvers for a shoulder dystocia.

When the umbilical cord lies beside or in front of the fetal presenting part, it is called a prolapsed cord . This is an emergency because oxygen is unable to reach the fetus due to cord occlusion. Figure 19.18 demonstrates a prolapsed cord. A prolapsed cord is usually diagnosed after rupture of the amniotic membranes, either spontaneously or artificially. The fetal monitor tracing will usually show a prolonged deceleration. The nurse suspects a prolapsed cord and does a vaginal exam. Many times, the cord with pulsation is felt in the vagina. At other times it cannot be palpated, but the assumption is made because of the prolonged deceleration. The nurse will lift the presenting part off the cord to allow for perfusion to the fetus. The nurse calls for assistance while keeping the presenting part elevated. An emergency cesarean birth will be performed, and the nurse’s hand will remain lifting the presenting part until the fetus is delivered.

A uterine rupture is defined as a tearing or an opening in the muscle of the uterus. Figure 19.19 illustrates a uterine rupture. It is seen more commonly in persons with a previous cesarean birth . Most ruptures occur during labor, but some occur during pregnancy. Uterine rupture is an emergency for the fetus and the pregnant person. The pregnant person can hemorrhage quickly, and the fetus can be deprived of oxygen. Time is important in this emergency. The nurse is aware that the fetus must be born quickly, usually via cesarean, and that the uterus must be repaired before the pregnant person has lost an excessive amount of blood.

Figure 19.19 Uterine Rupture The uterus is ruptured, and the head of the fetus is protruding into the abdominal cavity. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Risk factors for uterine rupture are a history of a cesarean or other uterine surgery, uterine trauma, polyhydramnios , and prolonged labor. If a fetal monitor is in place, the symptoms of uterine rupture are that the FHR no longer traces and contractions are not present. If the patient does not have an epidural, they may notice a lack of pain. Other signs could be late decelerations or prolonged decelerations and severe abdominal pain in the pregnant person. Vaginal bleeding may or may not be seen (Lumala & Atwijukire, 2021).

The nurse caring for a pregnant person attempting a VBAC is aware of the higher risk for uterine rupture. The pregnant person attempting a VBAC is on continuous monitoring to screen for fetal distress because this is sometimes the first sign of uterine rupture. When uterine rupture is suspected, the nurse quickly calls for assistance and prepares the person for an emergency cesarean birth. The nurse is prepared to order blood products because risk for postpartum hemorrhage is high. The perinatal team will be in the operating room to care for a depressed newborn.

An anaphylactic reaction to amniotic fluid entering the respiratory system is anaphylactoid syndrome of pregnancy (ASP) , also known as amniotic fluid embolus. The incidence of ASP is anywhere from 1 in 80,000 to 1 in 20,000 pregnancies; the incidence has a large range because the clinical diagnosis of ASP is usually done retrospectively or during autopsy (Barnhart & Rosenbaum, 2019).

For ASP to occur, an opening between the amniotic sac and the pregnant person’s venous system must exist. This happens at the time of rupture of membranes or at other times during labor and birth. Risk factors include:

• multiparity
• tachysystole
• advanced maternal age
• uterotonics
• cesarean birth
• uterine rupture
• uterine trauma
• premature separation of the placenta
• IUFD

(Fox et al., 2019).

Amniotic debris, vernix, hair, and other tissue enters the cardiopulmonary system, leading to shock similar to sepsis or anaphylaxis (Fox et al., 2019). Symptoms are respiratory distress , cyanosis , hypotension , and seizure . Treatment is to support the person’s respiratory and cardiovascular systems. Many persons go into cardiac arrest and require intubation and ventilator support. The majority of persons experiencing ASP will have disseminated intravascular coagulation. The mortality rate associated with ASP is 60 to 80 percent (Fox et al., 2019). Those who survive can have neurologic damage leading to seizures, confusion, or coma (Kaur et al., 2016). The role of the nurse is to assist the health-care provider, support the laboring person, and keep the family up to date on the interventions being performed. The nurse also anticipates the need for escalation of care to the intensive care unit for the laboring person and the NICU for the newborn.

The condition associated with the coagulation cascade in which the body releases all of its clotting and anti-clotting factors, leading to massive hemorrhage and organ failure is disseminated intravascular coagulation (DIC) (Fox et al., 2019). The incidence of DIC ranges from 0.03 percent to 0.35 percent, with developing countries having higher incidences (Erez et al., 2022). DIC occurs in response to placental abruption , ASP, fetal demise, sepsis, and preeclampsia . Symptoms of DIC are bleeding, petechiae, fever, hypotension, hypoxia, and localized hemorrhage. Treatment is correcting the initial cause of DIC. Other treatments are blood and blood-product replacement, intubation, and ventilation. Nurses are aware of the risk of DIC with preeclamptic persons who also have HELLP syndrome (Erez, 2022). See

Second stage labor is also known as the pushing stage. Complications can occur during this and any stage of labor. The laboring person is working very hard to push, and the fetus is working hard to be born. Because of the stress of pushing, the laboring person can become fatigued, and the fetus can exhibit distress. The nurse will monitor the laboring person and fetus for signs of distress. At times, the second stage can take longer than expected and may be diagnosed as prolonged second stage. At other times, the fetus has difficulty in engaging in the pelvis, causing failure to descend. The nurse works with the person to support the pushing effort and provide guidance and encouragement.

Prolonged Second Stage

Prolonged second stage labor is defined as a second stage labor lasting longer than 3 hours for a nulliparous person and longer than 2 hours for a multiparous person. Risk factors for prolonged second stage are use of epidural anesthesia , persistent occiput posterior position, and head circumference or birth weight above the 90th percentile (Lipschuetz et al., 2018). Complications to the birthing person resulting from prolonged second stage include chorioamnionitis , postpartum hemorrhage , operative vaginal birth , extended perineal lacerations , and cesarean birth . Prolonged second stage is also a risk factor for shoulder dystocia in the newborn.

Failure to Descend

Descent of the presenting part begins in active labor. During second stage labor, the fetal presenting part descends past the cervix, into the vagina, and out past the perineum. Failure to descend is defined as lack of change in the station for at least 2 hours. Many times, this is caused by fetal malpositioning, especially occiput posterior position (ACOG, 2020). Rotation of the fetal head by the health-care provider manually or with forceps can allow for increase in station and vaginal birth. At other times, failure to descend results in cesarean birth.

Laboring Person Fatigue

Second stage labor takes a great deal of energy and effort. Many times, laboring persons become fatigued and need a break from pushing. If the person can no longer continue pushing, the person is said to have labor fatigue. As discussed previously, one of the Ps of dystocia is power. With labor fatigue, the power is deficient, and second stage dystocia occurs. Labor fatigue can be prevented by waiting until the peak of the contraction to encourage the birthing person to bear down during contractions, providing food and drink to replenish calories, and allowing the fetus to descend or “labor down.” The nurse can support the laboring person and encourage these interventions to help decrease fatigue.

End-Stage Fetal Bradycardia

During the second stage, the fetal head molds to fit through the pelvis. At times, the compression and molding cause FHR decelerations. These decelerations can be early (mirror the contraction), late ( uteroplacental insufficiency ), or prolonged (bradycardia lasting longer than 2 minutes). Monitoring the FHR can be difficult as the fetus descends. Therefore, the nurse must compare the laboring person’s heart rate to the FHR to ensure the monitor is tracing the FHR. In cases of prolonged decelerations during the second stage, the health-care provider might expedite birth by performing an episiotomy, using forceps or a vacuum extractor , or by performing an emergency cesarean birth.

Legal and Ethical Issues

Laboring Person Fatigue and Request for Cesarean Birth

During the second stage, the laboring person can become very fatigued and discouraged. Many times, they will request to have a cesarean birth to stop pushing. They are not always making a sound decision because of their exhaustion. The nurse and health-care provider must closely evaluate the laboring person to determine if the fatigue is leading to a prolonged second stage or if the person needs a rest. Periods of rest during the second stage allow the person to relax, decrease stress, and regain focus. Rest is an important nursing intervention during second stage of labor.

During the third stage of labor, the placenta and the membranes are birthed. Several complications can occur during this stage. The placenta or parts of the placenta can be retained inside the uterus. The placenta can be implanted into the muscle of the uterus as well. Complications with the placenta can lead to postpartum hemorrhage, which can be a life-threatening complication. The nurse is prepared to treat postpartum hemorrhage quickly.

If the placenta has not delivered spontaneously within the expected 30 minutes, the health-care provider will determine if manual removal is indicated. If manual removal is not possible, the anesthesia provider is alerted of the need for a possible dilation and curettage ( D&C ) or hysterectomy. Occasionally, the placenta will partially detach, and the birthing person will begin to bleed and pass clots vaginally. This is an emergency situation requiring manual removal before the 30-minute waiting period. Nursing actions include emotional support and education of the birthing person and support person, requesting assistance in notifying the anesthesia provider of the probable need for surgery, administering pain medication, and administering uterotonics once the placenta is delivered.

Risk factors for retained placenta include uterine atony , placenta accreta spectrum, cervical closure , premature birth, and previous retained placenta (Perlman & Carusi, 2019). Congenital uterine anomalies such as bicornuate uterus increase the risk of retained placenta. Complications of retained placenta include postpartum hemorrhage, endometritis , and retained placental tissue.

After birth of the infant, the cervix remains open until the birth of the placenta. Complications can occur if the cervix closes prematurely. In those cases, the placenta becomes trapped in the uterus. Trapped placentas can lead to postpartum hemorrhage . Treatment is administration of nitroglycerine to relax the uterus and cervix for manual extraction of the placenta. After removal of the placenta, oxytocin should be given to contract the uterus to decrease hemorrhage risk. The nurse will monitor vital signs, observing for hypotension, tachycardia, and inadequate oxygen saturation.

In the third stage of labor , delayed umbilical cord clamping is recommended for the preterm fetus. Preterm infants have increased incidences of blood transfusion, poor circulation, and intraventricular hemorrhage (Bennett et al., 2019). Delayed cord clamping can help prevent some of these complications. However, preterm birth has a higher incidence of retained placenta. If the placenta has not delivered within the expected 30 minutes, the nurse should prepare for transferring the birthing person to the operating room for a D&C to remove the placenta.

The loss of a pregnancy prior to 20 weeks’ gestation is called a spontaneous abortion (SAB) . It can be complete or incomplete. With an incomplete abortion, products of conception, such as fetal or placental tissue, can be retained. If the tissue can be seen at the cervical os, the health-care provider can remove it using ring forceps . If the tissue cannot be removed and bleeding is present, the person is taken to surgery to have a D&C to remove those products. Infection and bleeding can occur if the uterus is not free of all products of conception.

Placenta accreta is the invasive adherence of part or all of the placenta to the uterus. Placenta accreta spectrum disorder describes all invasive placenta occurrences (Oppenheimer & Singh, 2022). Table 19.13 lists the different types of placentas in the placenta accreta spectrum disorders. The incidence of these disorders has increased as the rate of cesarean births has increased. The pregnant person’s risk is much higher, the more cesarean births that person has experienced. Other risk factors are age at delivery of 35 years or older, in vitro fertilization, placenta previa , and prior uterine surgery (Oppenheimer & Singh, 2022). The mortality rate of pregnant persons with placenta accreta spectrum disorder is approximately 7 percent.

Real RN Stories

Name: LW, RN
Years in practice: 16
Clinical setting: In-hospital labor and birth unit
Facility location: South Carolina

I remember being the labor nurse for a 21-year-old patient having her first baby. The labor and birth of the baby went well. Then, the midwife waited for signs of placenta separation. After 30 minutes the midwife attempted a manual removal and asked me to notify the physician backup that she was unable to separate the placenta from the uterine wall. The placenta was still undelivered when the physician arrived. After examining the patient, the physician informed the patient that the placenta was adhered to the uterus and a D&C was needed. Informed consent was obtained and I witnessed the consent. The patient had an epidural and the anesthesiologist re-dosed it for the procedure. The physician performed the D&C but was unable to prevent the uterus from continuing to bleed heavily. At this time a decision was made by the physician to perform a hysterectomy. The physician brought the patient’s husband into the operating room and explained the situation to both the patient and her husband about the cause, need for, and long-term effects of a hysterectomy on a patient at the age of 21. After facing the future of no more biological children, the patient consented to the hysterectomy. This was not an easy decision for either the physician or the patient and her husband, but I will never forget this physician’s patience when trying to prevent having to perform the hysterectomy and answering all the questions from the patient and her husband. When the pathology report on the uterus became available, the report stated the patient experienced placenta increta.

An accessory lobe of the placenta that is separate from the main placenta is called a succenturiate lobe . The blood vessels feeding the lobe usually run through the membranes to the extra lobe. Figure 19.20 illustrates a succenturiate lobe and vessels. If these vessels cross the cervix, they can create a vasa previa . During the third stage of labor, the succenturiate lobe can be retained, which can cause postpartum hemorrhage or infection if not removed.

Total blood loss greater than or equal to 1,000 mL or blood loss and signs or symptoms of hypovolemia within 24 hours after birth is considered postpartum hemorrhage. When hemorrhage occurs during the third stage of labor or the first hour after birth, it is considered an immediate postpartum hemorrhage. The American College of Obstetricians and Gynecologists recommends that postpartum persons who have lost more than 500 mL of blood after a vaginal delivery be assessed by the health-care provider. There are multiple causes of postpartum bleeding. Table 19.14 describes the causes of postpartum hemorrhage using the four T’s.

Uterine Atony

Uterine atony is the most common cause of postpartum hemorrhage. The uterus can become atonic after chorioamnionitis , magnesium sulfate infusion, prolonged or precipitous labor , overdistention of the uterus due to twins or macrosomia , or cesarean birth . Nursing actions in the first hour after delivery include assessment of the location and tone of the uterus. Upon discovery of uterine atony, the nurse will start vigorous uterine massage. Treatment of uterine atony can be oxytocin ( Pitocin ), methylergonovine ( Methergine ), misoprostol ( Cytotec ), carboprost (Hemabate) , tromethamine (Tham) , and/or tranexamic acid (Cyklokapron) . A full bladder can displace the uterus and not allow it to contract efficiently. The nurse empties the bladder to prevent or treat uterine atony.

Retained Fragments of the Placenta

After the placenta is delivered, the health-care provider will examine the placenta and membranes for completeness. Retained placental fragments or membranes can cause immediate postpartum hemorrhage. When fragments are retained in the uterus, the uterus is unable to contract properly to stop the spiral arteries from attempting to feed the placenta. If retained fragments are suspected, the health-care provider will manually evacuate the uterus.

Lacerations

Cervical and vaginal lacerations can cause immediate postpartum hemorrhage. Careful inspection is very important. If the nurse notices heavy vaginal bleeding and the uterus is contracted, inspection of the vagina for lacerations should occur. The health-care provider can assess for cervical lacerations using ring forceps to evaluate the completeness of the cervix. Lacerations are repaired using absorbable sutures. Figure 19.21 illustrates a cervical laceration.

When the uterus turns inside out, protruding through the vagina, called inversion of the uterus , it is a life-threatening complication in the third stage of labor (Kumari et al., 2022). This occurs more often with active management of the third stage. However, other risk factors can be precipitous labor, manual removal of the placenta, and traction on a short umbilical cord. The signs of uterine inversion are hemorrhage, shock, and pelvic pain. The nurse attempts to massage the uterus, but the fundus cannot be palpated. The most common complication is hypovolemic shock and vagal response to sudden stretching of the uterine ligaments (Kumari et al., 2022). Rapid treatment is necessary. The health-care provider will attempt to reposition the uterus by placing a fist in the uterus and keeping it in that position until the uterus contracts. Uterotonics will be administered once the uterus is returned to the proper position. The nurse will monitor for worsening signs of shock. Figure 19.22 illustrates a uterine inversion.

Certain complications develop during the process of labor and birth. These complications include undetected lacerations, alteration in oxygenation, altered neurologic status, and psychosocial dysfunction. The nurse monitors for and attempts to prevent these complications.

The nurse assesses lochia every 15 minutes during the first hour after birth. Normal lochia is dark red with small clots. Bright red, brisk bleeding is not normal. If the uterus remains firm, undetected lacerations can be the cause of the vaginal bleeding. Risk factors for perineal trauma include older age, higher BMI, primiparity, gestational diabetes , hospital birth, longer second stage labor, and higher fetal weight and larger head circumference (Bączek et al., 2022). Lacerations can lead to symptoms of hemorrhage (hypotension, tachycardia, and decreased oxygen saturation) prior to the laceration being detected. The nurse examines the vagina and perineum to discover any undetected lacerations. Once a laceration is detected, the health-care provider is notified, and the laceration is repaired. The nurse will monitor for continued signs of bleeding. The hemoglobin and hematocrit will also be monitored. The health-care team will use lab results, vital signs, and the postpartum person’s ability to ambulate and perform activities to determine the need for a blood transfusion.

Alterations in perfusion can occur during the birthing process. Pregnant persons with preeclampsia can have kidney damage due to vasoconstriction secondary to hypertension . They can also have a seizure ( eclampsia ) causing alteration in perfusion to the placenta and central nervous system. Preeclampsia with HELLP syndrome can lead to DIC, causing hemorrhage. Uterine atony can also lead to postpartum hemorrhage . Hemorrhage causes hypovolemia, which produces vasoconstriction in the peripheral vessels and shunting of blood to the vital organs. This causes alteration in perfusion of the extremities. Diabetes can decrease perfusion to the placenta because of abnormal aging of the placenta caused by elevated blood glucose. Other alterations in perfusion occurring during the postpartum period (hematoma, deep vein thrombosis, and pulmonary embolus) .

Signs of alteration in perfusion can be diminished peripheral pulses, decreased capillary refill, delay in milk production, and clammy, pale skin. Changes in vital signs can be seen, such as hypotension and tachycardia. Alteration in mental status can also occur. Kidney damage can result from hypertension, hypotension, or hypovolemia.

Nursing interventions include monitoring and increasing perfusion in the laboring and birthing person and notifying the health-care provider. The nurse will evaluate vital signs, oxygen saturation, nail beds, gums, and mucosa for color and temperature. Lowering the head of the bed and elevating the legs perfuses the heart and brain. Oxygen is administered if needed (Obermeyer et al., 2022).

Laboratory results should be monitored when altered perfusion is present. Proteinuria is present when kidneys are not being perfused. The 24-hour urinary output should be assessed. Hemoglobin, hematocrit, and platelets are monitored after postpartum hemorrhage. In massive hemorrhage or disseminated intravascular coagulation (DIC) , clotting studies and plasma fibrinogen should be monitored.

Alterations in oxygenation can occur during labor and birth. The most common cause of oxygenation complications is hemorrhage. Complications can also be caused by eclampsia, pulmonary edema , and pulmonary embolus. Signs of alteration in oxygenation include restlessness, cyanosis , nasal flaring, orthopnea, and use of accessory muscles. The nurse will assess respiratory rate, use of accessory muscles, nasal flaring, and abnormal breathing patterns. Auscultation for decreased ventilation should be performed. The person with altered oxygenation may have altered mental status or confusion that should be monitored. Nail beds and skin should be assessed for cyanosis. A pulse oximeter should be used to monitor pulse and oxygen saturation. Arterial blood gas tests might be ordered, and results should be monitored. Nursing interventions are elevating the head of the bed; administering oxygen; encouraging slow, deep breathing; and splinting for those post–cesarean birth persons who are coughing. The most important intervention is treating the cause of the alteration in oxygenation.

During pregnancy, birth, and the postpartum period, alterations in neurologic function can occur. The most common causes of these alterations are seizure, stroke , and ruptured brain aneurysm. These complications are most likely due to preeclampsia and eclampsia. Seizures, sudden abnormal electrical activity in the brain, can occur any time before, during, or after birth. The cause of progression from preeclampsia to eclampsia is unknown. Eclamptic seizures lead to hypoxia and neurologic dysfunction. Stroke can be attributed to severe hypertension. A stroke, or cerebrovascular accident (CVA), is a sudden loss of brain function due to lack of blood supply to the brain. Peripartum migraines, infection, and coagulation disorders have been associated with stroke (Zambrano & Miller, 2019). Treatment of stroke requires rapid response from a multidisciplinary team. If the seizure or stroke is associated with hypertension, treatment should focus on reducing hypertension. A brain aneurysm is a bulging or weakening in a blood vessel in the brain. Aneurysms can rupture due to severe hypertension or preeclampsia. It is not within the scope of this text to discuss these disorders in detail. Refer to a medical-surgical text for in-depth discussion.

Nursing assessment of these persons includes monitoring for level of consciousness, voluntary/involuntary movements of extremities, blood pressure, ability to speak, cognition, and oxygenation. The nurse will support the person by giving positive feedback, decreasing their anxiety, and involving the family in care. The nurse will monitor for aspiration, thought processes, skin integrity, and improved mobility. The nurse will communicate with the health-care provider if vital signs become abnormal or if the person is unusually confused or cannot communicate, loses consciousness, or has another seizure.

Pregnancy, birth, and the postpartum period can be an exciting time for many people; however, others have alterations in psychosocial functioning. Postpartum depression is a common change. Some persons have difficulty in bonding with the newborn immediately after birth. Birth can trigger negative emotions in persons with a history of rape or sexual assault. Birth trauma can occur from difficult births or from feelings of lack of autonomy or control. Alterations in psychosocial functioning can also occur due to substance use. Pregnant persons are usually screened for substance use during the prenatal period. These persons should be offered assistance for their substance use disorder. When in labor, some persons are under the influence of substances. The nurse should be aware of the symptoms of certain substances. Cocaine and methamphetamine use causes higher risk for migraines, seizures, prelabor rupture of membranes, and placental abruption (National Institute on Drug Abuse, 2022). Infants born to persons using stimulants have symptoms of irritability, hyperactivity, tremors, high-pitched cry, and excessive sucking. Heroin use in pregnancy causes neonatal abstinence syndrome ( NAS ) in newborns; infants with NAS have symptoms similar to those of stimulant-dependent newborns, with the addition of gastrointestinal problems (National Institute on Drug Abuse, 2022). Alcohol use can result in fetal alcohol spectrum disorder , which affects fetal brain development and can cause birth defects. These defects can cause emotional and cognitive problems for the life of the offspring. If the nurse suspects the pregnant person is using an illegal substance, a drug screen can be obtained during pregnancy and at delivery. The nurse should also notify the nursery or NICU if the results are positive.

The use of forceps or vacuum to assist with the birth is considered operative delivery . These deliveries can be difficult for both the laboring person and the fetus. However, in certain situations, the use of these instruments can protect the person or the fetus by expediting delivery.

Obstetric Forceps

The metal instruments placed on the fetal head to rotate the head or assist in delivery of the fetus are called obstetric forceps . The use of forceps during labor is indicated for maternal exhaustion and when the birth must urgently occur, such as when fetal heart rate decelerations are noted. This can be an alternative to cesarean birth . Obstetric forceps are designed to fit the fetal head. They cradle the fetal skull to apply traction, rotation, flexion, and extension, as seen in Figure 19.12 (Shabib & Black, 2022). Indications for forceps birth include nonreassuring fetal heart rate , prolonged second stage of labor , and delivery of the head after a breech presentation . Forceps birth can be attempted only if the cervix is completely dilated, the membranes are ruptured, the fetal head is low in the pelvis, and the provider does not suspect cephalopelvic disproportion (Shabib & Black, 2022). Complications to the birthing person when obstetric forceps are used include lacerations of the vagina and cervix, pelvic hematomas , urethral and bladder injury, rupture of the uterus, and posttraumatic stress disorder (PTSD). Fetal complications include facial lacerations and nerve damage, cephalohematoma s, skull fractures, intracranial hemorrhage , and seizures (Shabib & Black, 2022).

When the health-care provider makes the decision and obtains consent from the birthing person to use forceps to deliver the fetus, the nurse performs several actions. The nurse assists the person into the lithotomy position and ensures that the bladder is emptied. If the person has an epidural, the nurse can call the anesthesia provider to ensure the person has adequate pain relief. The neonatal team should be in the room in case of newborn complications.

Legal and Ethical Issues

Consent for Operative Delivery

Upon admission, the laboring person signs consent forms for birth. Because an operative delivery is a deviation from normal, informed consent should be requested and given by the laboring person for use of forceps or vacuum. The health-care provider should explain why the operative delivery is necessary, the risks and benefits of the procedure, and how the procedure will be performed. The provider should allow time for questions and ensure shared decision making. The health-care provider is responsible for providing this information in a nonbiased way. For consent, the person must have the mental capacity to understand and make that decision.

Vacuum Extractor

A vacuum extractor is a device used to help deliver the fetal head during the second stage of labor. The vacuum device usually features a soft, silicone cup that fits onto the fetal head. A pump and gauge attach to the cup to apply the proper amount of suction. Once the vacuum is applied to the fetal head, traction is placed to assist the birth while the birthing person is pushing. Indications for a vacuum-assisted delivery are the same as for forceps-assisted delivery. Contraindications to the use of the vacuum include face or breech presentation, cephalopelvic disproportion, fetal head anomaly, preterm fetus, or fetal bleeding risk (Shabib & Black, 2022). Complications include neonatal injury, including superficial scalp markings, retinal hemorrhage, cephalohematoma, subgaleal hematoma, and intracranial hemorrhage (Shabib & Black, 2022). The vacuum can cause perineal and vaginal lacerations to the laboring person.

When the provider has indicated a need to deliver the fetus using the vacuum extractor and consent has been obtained, the nurse assists the person into stirrups. The vacuum system is checked for leaks. The cup is placed on the fetal head, and the vacuum pressure is increased during the contraction. The pressure is decreased between contractions. The nurse ensures the pediatric team is available for newborn complications. Figure 19.13 demonstrates the application of the vacuum.